EMS Protocol of the Week - Suspected Myocardial Infarction (Adult)

Diaphoretic? Clutching your chest? Might just be your excitement for another EMS-PoW, but it might also be a heart attack! Hard to tell, I know, so it’s probably just safer to call 911.

When dealing with a suspected MI, EMS will administer 324mg of aspirin orally, starting at the CFR level. BLS providers will immediately request ALS backup, but importantly, if the nearest ALS unit is farther away than the nearest appropriate hospital, BLS will instead transport the patient for further evaluation. If the patient is already prescribed nitroglycerin, BLS can help the patient to take it (assuming no erectile dysfunction meds have been given in the preceding 72 hours), but they do not have their own to give. 

Once ALS is on scene, they will perform and interpret a 12-lead EKG – this will assist in determining whether it is more appropriate to bring the patient to the nearest hospital or to bypass said hospital for the nearest STEMI/PCI center. En route, they can also administer their own nitroglycerin for persistent chest pain (again, assuming no ED meds, as well as a systolic BP > 100mmHg).

Not a lot for you all to do on the OLMC phone, but keep in mind that the decision for closer hospital vs longer transport to STEMI center is the main reason behind EMS calling for these sorts of cases. Listen closely to the case details, as well as the paramedic’s description of the EKG (if they have not sent it electronically) to help answer that question.

See you all next week for more! www.nycremsco.org or the protocols binder to tide you all over until then!

 Dave

EMS Protocol of the Week - Anaphylaxis (Pediatric)

Lots of suspense from last week’s cliffhanger, I know, but basically, the pediatric anaphylaxis protocol plays out largely the same as its adult counterpart, just with peds-relevant dosing, along with a predilection for dexamethasone over methylprednisolone, particularly for kids less than 2 years of age.

Double check your dosages! Need a reference? That’s what www.nycremsco.org and the protocols binder are for!

Dave

POTD: Winter is Coming.

Let’s talk about FROSTBITE, BRRRRRRR.

Background

• Results from the freezing of tissue that are exposed to temperatures below their freezing point, resulting in direct ice crystal formation and cellular lysis with microvascular occlusion

• Most of the damage occurs as a result of a freeze thaw cycle with endothelial damage and cellular death resulting in osmotic gradient changes, initiation of the arachidonic acid cascade, vasoconstriction, and hematologic abnormalities including thrombosis

• Risk correlated with temperature and wind speed

• Risk is <5% when ambient temperature (includes wind chill) is > –15°C (5°F)

• Most often occurs at ambient temperature < –20°C (–4°F)

• Wetness and humidity increase the risk (water has 25x thermal conductivity of air)

• Can develop within 2-3sec when metal surfaces that are at or below –15°C (5°F) are touched

• Most commonly affects distal part of extremities, face, nose, and ears

• The severity of irreversible damage is most closely related to ambient temperature and length of time the tissue remains frozen

• High-risk groups: outdoor workers, elderly, homeless, drug or alcohol abusers, psychiatric disease, high-altitude or cold-weather athletes, military personnel

• "Hunter's response" - prolonged repeated exposure to cold is protective

Classification

Frostbite is classically categorized into four levels of injury.

Management

The initial treatment in the Emergency Department for all degrees of frostbite is the same. Addressing ABC’s, trauma evaluation, removing wet and constrictive clothing, treatment of concomitant hypothermia (must rewarm to a core temperature of at least 35°C), and identification of other injuries should be confirmed in all cold injury cases if warranted.

• THAWING: Do NOT attempt until the risk of refreezing is eliminated. Refreezing will cause even more severe damage. Rapid active rewarming is the core of therapy and should be initiated as soon as possible. Best performed in a circulating water bath around 37°C to 39°C. Frostbitten faces can be thawed using warm water compresses, and ears may be thawed with small bowls of warm water. Immersion rewarming can be discontinued when the affected area developed a red or purple appearance and becomes pliable to the touch.

• Analgesia: rewarming is very painful, treat your patient's pain!

• Local wound care: Gently dry, elevate, and apply bulky dressing to the affected area. Compartment syndrome is a known complication, so maintain a high suspicion.

• Update tetanus as needed

• Empiric prophylactic antibiotics are not needed and are controversial.

• Surgical management may be required if wet gangrene or infection occurs, but this is typically reserved for late frostbite management after the rewarming phase in days to weeks following initial presentation

Dispo Dispo Dispo

• Patients with superficial local frostbite may be discharged home if social circumstances allow. Patients unable to care for themselves adequately should never be discharged into subfreezing temperatures.

• Significant injuries will require admission.

References:

http://www.emdocs.net/brrr-ed-presentation-evaluation-and-management-of-cold-related-injuries/

http://emedicine.medscape.com/article/926249-treatment#showall

https://wikem.org/wiki/Frostbite

https://www.emrap.org/episode/environmentalem/hypothermia

https://www.emrap.org/episode/environmentalem/frostbite